Archive for Blog – Page 4

Immediately after an election expected by the end of May, there will be a plethora of health policy papers and advocacy campaigns unleashed on yet another fragile minority government (NDP or Liberal) by gangs of screaming banshee warriors that we refer to as “healthcare interest groups”.

The proposals they make will mostly be structural in nature — each one largely reflecting the narrow self-interests of the group, while masquerading as being “in the public interest”. But this is a game about “power” and “money”.

I know about this stuff.

I taught courses on interest group strategies and tactics in political science at Carleton University in the early-’70’s. In the mid-’70’s, I was a lobbyist at the Canadian Book Publishers’ Council advocating on behalf of publishers. I was so effective at bugging the government that Bill Davis’s Officereached out and brought me into their inner circle — as a speech writer/policy-wonk/strategist — which I joyfully did for 12 years.

I was then employed by the President of the Canada Post Corporation in the mid-80’s — helping to transform the old Department of the Post Office (with its billion dollar annual deficit) into the modern, smooth-running, small-profit, strike-free and lovable crown corporation that it has been up until just recently.

Trapped in Ottawa from Monday to Friday, I wrote a book in my spare time in the evenings called: “Lobbying Queens’ Park: Strategies & Tactics For The Peterson Minority Government“. The book sold like hot-cakes. A Liberal government? What’s that? A minority government? What’s that? Lobbying? Influencing the way government thinks through strategic communications and coalition-building? How do you do that?

In those days, in terms of healthcare interest group power, there was just the OMA/OHA — and then everybody else. Not anymore. Today a variety of healthcare interest groups have evolved over the past ten years as sophisticated, highly-strategic, “power players” who know the buttons to push in the GR (government relations), policy advocacy and strategic communications business. So, it is not just the two “dancing dinosaurs” at the party anymore. There are many. And some of them are good at it.

However, as I would warned students taking my Interest Group Politics course at Carleton University: people with weak stomachs should always avoid watching two horrible and sickening processes: the making of sausage, and the making of public policy. Because, you see … you have no idea about the kind of crap that goes into both of those products!

For the next few weeks, I’m going to blog on the various lobby campaigns that will be launched this year — starting with the most active interest group — the CCACs.

Ontario’s fourteen CCACs are playing an expanding role in health services delivery.

They provide vital services to 650,000 patients/clients in a much more cost-effective way. It costs $384 per day less to care for a patient with high needs in the community. It costs $50 per day less to care for a senior with moderate needs in the community, as compared to a long-term care home.

Indeed, by supporting people at home and in the community, our $2.2 billion CCACs and community support services together have created cost avoidance savings of $210 million over the last three years by shifting care from more expensive parts of the system.

The Ontario Association Of Community Care Access Centres was headed-up byformer Deputy Minister Margaret Mottershead for several years. She was replaced on an interim basis by another retired MOHLTC Deputy, Dan Burns.

Dan hired the consulting firm of Deloitte Inc to research and help prepare a series of four policy discussion papers on “serving the needs of our aging and diverse population over the long term” — most likely with the “evolving and expanding role” of the CCACs as a concluding theme throughout their papers.

The four discussion papers were guided by a Public Affairs Committee, with coaching from Dan. Dan’s successor at OACCAC is another former Assistant Deputy Minister, Catherine Brown. She will have a mandate to convince her former colleagues — who will be the policy-makers — about the wisdom of the policy positions that have been articulated in their four papers.

Given that the OACCAC has mostly been run by former senior public servants, several groups express concern about the actual status of the CCACs.

Are they “Helpers” — like the LHINs and the MOHLTC; or, are they “Doers” — like the CHCs, nursing homes and hospitals?

While they can’t be both, many sense that the CEO of OACCAC may in fact function as “an external ADM”. Catherine Brown now has her chance to put her stamp on what should be the future of the CCAC sector by marketing the four Deloitte policy papers and pushing for government funded exert panel who will let the government “off-the-hook” in the same way the Drummond Report enabled the government to sail through the last election being able to say: “We’re studying that.”

While the language of these papers contain lots of references to “patient-driven healthcare”, by definition and function, the bottom-line purpose of these policy advocacy papers is to position the CCACs to play an ever-expanding role as a direct service provider within the evolving health sector.

There is nothing wrong with that. This is what self-interest groups do. They operate in their self-interests — while making it sound as much as possible like it’s really all about “better patient care”. All groups do this. That’s the game. That’s how it is played.

But I think the CCACs are becoming more aggressive now because over the past several years, they have not had much respect/support in the delivery system, nor in the government. I don’t know why the delivery system and senior public servants don’t hold the CCACs in higher regard professionally. They certainly are well experienced at complex change management challenges.

They underwent significant restructuring from 43 CCACs to just 14 a few years ago. Today there is a critical mass of demonstrated managerial talent and innovative capacity in this too often undervalued sector. Indeed, a number of CCAC CEOs and their senior directors are often more experienced, competent and innovative than some of our hospital CEOs and vice-presidents — who are, nevertheless, paid a great deal more money.

Of course there are also some CCACs (as well as LHIN and hospitals) that operate as command-and-control bullies with their suppliers, staff and clients. There are also several that have demonstrated a genuine focus on patient/clients; a zest for innovation; and, for truly being “great community partners” — focused on the community’s best interests.

In many communities, the CCACs have been the “connective tissue” that holds much of the local healthcare services delivery system together — in very constructive and helpful ways. For many CCACs, true, pragmatic, results-oriented “partnership skills” are a strength. In others, not so much.

The CCACs have been invaluable as relationship-builders with their multiple partners across the delivery system. A well-managed CCAC truly strengthens the whole system.

While the same could be said about other sectors, the mindset at Queen’s Park is that the Health Science Centres, large community hospitals, CCACs, home support agencies, mental health service providers, and illness prevention services are somehow a pecking order of descending “hierarchy” — rather than the flexible components of a health service delivery system that can be reconfigured to meet the emerging needs of the population served.

Lots of people also say that our hospital boards are much more sophisticated than the CCAC Boards. However, in my experience, the CCAC Boards that I have facilitated, are just as good as, and perhaps even more reflective of the community than many hospital boards.

There is also about the same number of dysfunctional organizations in both the CCAC and acute care sector. Nevertheless, despite their actual level of managerial and governance competence, the CCACs seem to feel they need to step-up to the sometimes mean-spirited criticisms and political threats that they face from the Tories and NDP — who say they would “get rid of them, and the LHINs”, if they come to power.

Indeed, the Hudak Tories say that under a PC government, the work currently done by CCACs, would be done under the guidance of the local hospital. They propose that additional people be added to the existing hospital board to represent the CCAC perspective — along with other agencies that would be managed by the PC’s “Hospital Hub Model“.

But it’s not just politicians who want to eliminate the CCACs.

The Registered Nurses’ Association Of Ontario suggests that the CCAC Case Managers be located in primary care, and then eliminate what they say is “unnecessary bureaucracy”. So the CCAC’s face some tough challenges in the public policy/political arena right now. There are many complex and threatening dynamics that are at play. The stakes are very high.

Joining the debate about health system design is Patients Canada Board Chair Michael Decter who, on behalf of patients, is advocating for a single bureaucratic structure by merging the LHINs and CCACs.

To help them in their public affairs and lobbying efforts, the OACCAC has hired the professional government relations firm of Strategy Corp — which has both Liberal and PC party senior operatives who will help them “sell” their version of health system reform to the two mainline political parties, while keeping the government’s partner (the NDP) fully informed.

“There is no question, the CCAC’s efforts to lobby has paid off big time. The Minister does not treat them like any other Health Service Provider. One prominent healthcare leader told me recently that she ignores the significant criticisms of some CCACs — who the Minister and government treat as more significant allies than their sister crown agencies, the LHINs.

This is system redesign by stealth. “As the Minister pushed CCACs into the direct services business, nobody wanted to speak up. They were afraid of the “inner circle”, says this respected CEO. The opposition parties kept raising the policy question: are CCACs in a “conflict-of-interest” if they are both healthcare service suppliers, and care coordinators who contract out the work?

The answer of course is “yes” — a system design flaw that will create unintended outcomes.

Several other Health Service Providers have been quietly grumbling. They kept waiting for some sort of open and transparent public policy development process that would have given them a chance to challenge, or offer more cost-effective ways to delivery services — rather than the unilateral decision to simply shift direct service provision to the CCACs without an open policy process.

So the CCAC sector has gained power and influence as part of an “inner circle” that influences Queen’s Park.

When you strut on the field to play hard-ball politics, the draw-back is that you become the target.

According to insiders, the MOHLTC and the OACCAC have discussed the need for a sector-wide policy debate about the future of the community sector’s growth, management and governance and what that transformation journey might look like.

That’s why the OACCAC has created their four discussion papers. Indeed, we should thank the OACCAC for their leadership in kicking off what I hope will be a truly open and honest dialogue about our future healthcare system. The OACCAC’s policy papers are entitled, “Health Comes Home“. The four policy papers are available @ OACCAC Web-Site.

In these papers, the CCAC sector advocates that Ontario introduce point-of-care user fees and expand the role of the private sector and “use private-sector interests and investment to complement the public health-care system”.

Their goal, says their first paper, is: “to begin an earnest dialogue about how we come together to create a high performing health system that optimizes home and community care.” Good idea! We need these dialogues at the LHIN and Health Link levels — among boards, CEOs, managers and clinicians.

However, to begin the dialogue, we all really need to be aligned on our basic non-negotiable fundamental high-level principles and values — the ones supported in public opinion polls for decades. “Values” like our future health and community support system will have universal/equal access — a system with “no user-fees“.

The OACCAC tackles the issue of resources head-on saying that “given rising expectations for choice and flexibility in their care options, Ontarians may well increasingly need to assume more financial responsibility for the cost of their care.” In their fourth paper, these are called “means-tested private pay” options.

While we already have a mixed public sector healthcare delivery system, the CCAC seems to be advocating for a more expanded role for the profit-focused companies to deliver healthcare services.

The issues that the OACCAC has put on the table is the need for “more money” for care services in the community system from consumers/patients — which would mean less money would need to be reallocated from acute care to community care and less money would have to come out of the estimated 30% waste in the system — if people simply “paid extra” for some services.

So, the healthcare system would be “off-the-hook” — if taxpayers and patients simply paid more.

When I asked five or six people what they got from these OACCAC position papers, they replied that the CCACs were advocating for “co-payments” and “user fees” and wanted a public/stakeholder debate on the subject.

There has of course been considerable scholarship and numerous studies conducted over the past decade in this country on the costs/benefits of healthcare user fees. So really, what’s to debate — if we believe in evidence-based decision-making? We know from these many studies that user fees are sub-optimal, and don’t work. They are dead and have been buried.

Health economist Bob Evans refers to “user fees” as “zombies”. “We kill them off with research, bury them, and then, a few years later, here they are again, risen from the dead yet again”, says UBC’s Evans.

By “putting all the issues on the table”, has the OACCAC unintentionally become a “stocking horse for the advocates for co-payments and user fees”? Since all three political parties have — up until now — rejected “user fees” as an option for obtaining the revenue for expanded seniors’ services, it would be helpful to learn if the OACCAC would propose to shift resources from the acute care sector to community care. Now that would be putting the elephant on the table!

From a senior citizen taxpayers’ perspective, they want to shift their healthcare investments from acute care to chronic care/home care, and to home support services.

Having paid handsomely for their entire lives for health services, seniors and taxpayers have consistently rejected user fees as an option — which explains why no political party is prepared to publically call for user fees.

This might be a great idea in Utah, but it will not be very acceptable in Ontario.

Rather than considering user-fees as the first option to generate “more revenue for the same services” offered by the CCACs, why not instead put the CCACs best thinking about how to reduce the estimated 30 percent waste in our healthcare delivery system — by even just a modest amount? That would certainly generate considerably more revenue than “user fees” would ever raise.

I think these Health System Future Dialogues/Stakeholder Debates that the OACCAC wants to encourage, could indeed generate a lot of sparks — if they include asking patients/taxpayers for even more money for the services they having been paying for all these years. Most taxpayers don’t have the type of rich pension plans enjoyed by most of the health sector. Baby boomers want to shift resources from services they require less of (i.e. acute care), to services they require more of (i.e. home support/care).

Patients — as taxpayers and “owners” of our healthcare system — want the high-quality services that they have already paid for. So, as we approach the Spring election, let the Earnest Dialogue begin!

I don’t understand why the OACCAC thinks it is a good idea to infuse the issue of “user fees/co-payments/or means-tested private pay” into the Spring election, but good for them: let each political party explain how they will pay for increased home care — by reducing the 30% waste in our $48 billion system; shifting resources from acute care; to community care; or user fees? Or, combinations?

Next week I’ll blog on the Nurses and CHC Lobby.

FORWARD THIS BLOG TO PEOPLE YOU THINK WOULD GAIN SOME DIFFERENT INSIGHTS ON OUR CURRENT CIRCUMSTANCES.

Many healthcare leaders say they don’t feel “safe” in the current healthcare environment. One hospital CEO I spoke with recently said “It is not like it was ten years ago when we all tried to stand out by being innovative and creative. Today, you don’t see many innovative CEOs doing interesting things. This is a risk averse environment. Senior managers have learned to keep their heads down, be compliant, and, in a few years, collect a really good pension.”

This is the logical outcome from a system dominated by fear and anxiety — and it will get much worse if we don’t push back to find a less threatening management style and if we don’t become more emotionally intelligent.

In my organizational transformation practice over the past 20 years, I’ve learned more and more about how and why emotional intelligence is perhaps the most important success driver. The latest research on brain functioning and human behavior proves Deming’s coaching advise was spot on. Neuroscientist Evian Gordon says that the fundamental organizing principle of the brain – at a very primal level – is to “minimize danger” and “maximize reward”.

CEO’s and transformational change journey designers need to be aware that when the journey (or the leadership) create threatening environments, they will create an “amygdale hijack” (limbic part of brain which triggers fight or flight responses).

In “Managing with the Brain in Mind”, David Rock in Strategy & BusinessMagazine summarizes what happens to people who are placed in an emotionally threatening environment at work. He says “the threat response is both mentally taxing and deadly to the productivity of the person – or a whole organization. Because this response uses oxygen and glucose from the blood, they are diverted from other parts of the brain, including the working memory function, which processes new information and ideas.” The research demonstrates that “this impairs analytic thinking, creative insight and problem-solving: in other words, just when people most need their sophisticated mental capabilities, the brain’s internal resources are taken away from them.”

The conclusion: when leaders trigger a threat response, people’s brains become much less efficient. So when Queen’s Park slaps down a Performance Agreement with the LHIN in which they are to be “held accountable for things over which they have no control”, the fear-driven dynamic begins. Same thing if a LHIN wants to hold a HSP accountable for things over which they have no control. Or when a CEO holds a manager unfairly accountable. This is unproductive bullying, and it is a failing strategy that is modeled by the very top leaders in our health care delivery system today.

David Rock’s research demonstrates that “when leaders make people feel good about themselves, clearly communicate their expectations, give employees latitude to make decisions, support people’s efforts to build good relationships, and treat the whole organization fairly, it prompts a reward response. Others in the organization become more effective, more open to ideas and more creative. They notice the kind of information that passes them by when fear or resentment makes it difficult to focus their attention. “

It is this feedback — from the heart, not the head — that ignites creative genius and intuition, keeps us honest with ourselves, shapes trusting relationships, clarifies important decisions, provides an inner compass for life and career, and guides us to unexpected possibilities and breakthrough solutions”. Emotional Intelligence is what enables us to move from the KnowingandDoing phase — into the Being phase of life.

The very sad part about the current environment in the health sector is that top-down fear mongering seems to be the only approach that our leadership wants to practice.

Fear of punishment, and fear of never getting into the inner circle have become the leadership style modeled from the top. It is very discouraging for people who actually want to “fix things”, or make things better.

Nevertheless, around us are vivid examples of emerging excellence in care delivery. Hands-on experience, and transformation case studies, have convinced me that the estimates of 20% to 30% (of LHINs, CCACs, hospitals, Community Health Centres, home support agencies) that are fully engaged on a positive change journey towards improvement, are valid estimates.

I keep uncovering wonderful case examples of innovation that have broken out in our Ontario healthcare delivery system. When I find these examples I do my best to shine a little light on these projects and on the outstanding leaders who made them happen in my blogs.

When front-line staff, middle managers and senior mangers get positive feedback on their improved performance and their innovative breakthroughs — which they know is deserved — such acknowledgements of “good work”, spurs everyone to even greater heights. It’s our human chemistry.

“Fear” and “anxiety” will never lead to an improved and transformed health system. That takes “creativity” and “innovation”. That takes emotional intelligence.

I’ve written about various emotional intelligence tools. I like the Personalysis framework best because it has the very same framework as the Balanced Scorecard and the most advanced tool of its kind available (see Personalysis).

What we know is that if leaders are to successfully lead and manage their organization through a fundamental transformation, they need to have empathy. Paradoxically, the route to empathy is through self-awareness.

Engaging leadership teams with these sorts of tools provides them with frameworks that will enable people to more comfortably raise itchy issues and resolve relationship problems because people will become more self-aware, more emotionally intelligent.

Being self-aware involves paying introspective attention to our own experiences — including our feelings, as they happen. The more self-aware we are, the more skilled we will be at reading others’ feelings, and the more empathetic we can be. When we are empathetic, we have the capacity to perceive the subjective experience of another person. We demonstrate empathy when we imagine another person’s feelings, emotions, and sensitivities, think about how we might “feel” in their situation, and then behave in an appropriate way.

But to be empathetic, it is necessary to be self-aware. When we are self-aware, we are in touch with our own emotions, and therefore are more able to read others’ feelings. Empathy leads to quality relationships, integrity, trust, and good communication. Many people fear being empathetic and showing compassion at work, because there is a mindset that emotions do not belong there, and therefore must be avoided at all costs. However, when people are emotionally upset, they are likely unable to remember, learn, or make decisions clearly.

However, self-awareness extends beyond emotions to knowing, at any given time, things like what our energy level is like, our receptiveness to new ideas — or our ability to focus on a task. It is about knowing yourself. And, when we are in touch with our own feelings, we can “read” someone else’s feelings — without them even having to tell us how they feel.

Rockbottom: empathy involves being sensitive to others’ feelings and concerns, taking their perspective, and respecting differences that people may feel about things. Since people’s feelings are not always put into words, we must also be able to read “non-verbal” cues, such as facial expressions.

Again leaders can learn a lot from brain research and human behavior. In “Managing with the Brain in Mind”, David Rock points out that “when a leaders is self-aware, it gives others a feeling of safety even in uncertain moments. A self-aware leader modulates his or her behavior to alleviate organizational stress and creates an environment in which motivation and creativity flourish.” Rock points out that “one great advantage of neuroscience is that it provides hard data to vouch for the efficiency and value of so-called “soft skills”. It also shows the danger of being a hard-charging leader whose best efforts to move people along also set up a threat response that puts others on guard.”

In the end, it is about striking the right balance: while being empathetic and developing the skills and capacity of people to manage change with emotional intelligence is a best practice step, the bottom-line is: change must happen!

While 90 percent of humans would rather die than change, it is the leader’s task to convince everyone that “true safety” lies in change, not the status quo.

As change happens, it should also lead to real measurable improvements.

Bottom-line: you are accountable for bottom-line outcomes listed in your personal Accountability Agreement — which needs to be designed with the best practice approach of balancing the “supports required to be successful”, with the “outcomes for which you are accountable.”

In times of chaos and bifurcation, we need balanced practices like these, rather than public relations, spin-doctoring communications and cover-ups of the truth — common practices in highly political environments to maintain some “control”.

But real change is coming immediately after the election expected at the end of May.

The status quo for Ontario’s healthcare delivery system cannot, and will not survive. If people are experiencing their current environment as “threatening”, they will be guarded and risk adverse. Fear and anxiety will be very present – and bottom-line results will not flow in such a stressful environment. As successful change practitioners say: “it’s about relationships, relationships, relationships.” People must be made to feel “safe”.

As the father of total quality management, Edward Deming said: “First, drive out fear!” Change management practitioners also provide wisdom for transformation journey designers like: “Slowing down, in order to speed up”; and, “Slow is better”, etc.

However, best practices also suggests that at a critical stage of the strategy development process, a much more rapid pace of change will be required to mobilize and align the organization and system. The bottom-line for CEO’s and change journey designers is that you have to learn how to go slow and fast – at the same time. That can be very difficult for people.

That is why we need empathic and emotionally intelligent leadership in these chaotic and uncertain times. If this blog has made you curious about this approach by all means, try Personalysis on yourself, it will be the best $200 investment you ever made. If you want to test this remarkable tool, give me a call @ 416-581-8814.

Having read several days of hearings of the Legislative Committee reviewing the LHIN Legislation, and having spoken with a few other policy wonk/nerds who also read the same transcripts, I must say, my nerdy friends and I found that these hearings profoundly disappointing.

Given that my own roots in the health system come from my involvement as the Senior Policy Advisor and Chief-of-Staff to a Minister of Health, you would think I ought to be more of a realist about politicians and the political process.

I had hoped that our politicians would grasp that “system design” is not about politics. It’s about designing the healthcare delivery system to work. That’s the “science of systems”.

A system is a set of interrelated component parts and processes that are intentionally designed to produce an outcome. The wisdom from organizational scientists is: every system is perfectly designed to produce the outcomes that it produces. While our healthcare delivery system will succeed — or fail — based on how it is designed, you would never know that by reading the transcripts of these hearings on the LHIN Legislation.

The members of the Legislative Committee are not focused on “system design issues”. They are not focused how to design for the outcomes required by patients and taxpayers. Unfortunately, they are mostly focused on political advantage and blame. Meanwhile, the presenters at these hearings have simply ignored the elephant in the room: that the legislation providing for local empowerment/devolution was never implemented. But nobody wants to explain why!

The “system design” that the committee is reviewing, the “Local Health Integration Networks“, located in fourteen regions, with Governance Boards of 9 members, and a staff at each of about 25-35 people, have a mandate to do the following:

Engage all of the partners in the LHIN to produce an annual Integrated Health Services Plan (IHSP);

Hold all HSPs “accountable” for achieving the results promised in their Accountability Agreements as a continuous quality improvement process; and,

Under the devolved authority provided by the legislation, LHINs were supposed to allocate resources across their delivery system to achieve the goals of the IHSP developed by the Health Service Provider partners. However, this provision was never implemented, so the “LHIN system” does not work.

Remember the definition: a “system” is a series of interrelated components and processes that are designed together to create an intentional outcome. In this case, the LHIN system was designed to empower local communities to transform themselves to meet the emerging needs of the population they serve. They have the plan (their IHSP), and through their LHIN, they were supposed to have the authority to allocate the money to implement their plan.

While we still insist on calling these crown agencies “LHINs”, the fact is that they were left as incomplete. They are not really “devolved local authorities”. Therefore, they are not really “LHINs” at all! There is no “LHIN system”. It was designed, but never built.

Is a car still a car if it does not have an engine? Or, is it simply the “body of a car”, or the “illusion” of a car? Similarly is a LHIN really a LHIN, if it does not have the authority to allocate resources?

None of the three political parties — and none of the hearings transcripts — were focused on the most important issue: Why was the LHIN design never implemented? Instead, the NDP and the PCs have apparently joined an alliance with the Liberals to support the MOHLTC’s self-interested opposition to devolution. Why? Why are all three political parties opposed to local empowerment? Why are they each in favor of centralized control?

If there is to be fewer resources available to healthcare services over the next several years, it will be the faceless bureaucrats at Queen’s Park who decides what gets funded, and what gets less funding. Are any of our political parties in favor of “local empowerment”? Surely our politicians would be in favor of “local empowerment” because “all politics are local”… but maybe not. Maybe each political party actually wants to keep the government — and the MOHLTC — in the game of being what George Bush called “the deciderer”.

But we already know that the MOHLTC as “the deciderer” is not a good design. Done that, been there. That’s why the DHCs and LHINs were created — as a countervailing force against centralized decision-making. The DHCs and LHINs are like “the eyes and ears of the Minister”.

That’s also why MOHLTC set out to destroy the DHCs, and that’s why they have told Queen’s Park that LHINs can’t be trusted with all the power and authority that was set out in the original legislation. Of course the moment our new government is elected and faced with deciding on the expected health spending cutbacks at the local level, our politicians will — at that moment — discover that it would be much better if people blamed the LHINs for these tough decisions, than our provincial politicians.

The Opposition Parties will claim (as usual) that the provincial government is “hiding behind the LHINs”, rather than supporting local empowerment. But since devolution actually never took place, Queen’s Park has been able to flourish — growing from five ADMs before we had LHINs, to 13 ADMs, two Associate Deputies and a Deputy Minister today.

There isn’t any data that would indicate any improvements in our healthcare delivery system flowing from all this top-heavy centralized bureaucratic growth over the period where, officially, the system was to be devolved, and Queen’s Park was to shrink.

To be fair, most people would acknowledge that within the ranks of the senior Health Ministry executives are a few knowledgeable, compassionate dedicated and effective senior public servants. I don’t think people feel this is some sort of “evil empire”, I think people simply feel that local communities are best positioned to lead their own transformation — as it was set out in the legislation back in 2005.

So how come our public servants have had such difficulty over the past eight years implementing the “Made-In-Ontario Devolved Model“. Shouldn’t the Committee learn about that?

The fact is, if our government implemented “devolution“, as set out in the legislation, it would result in a 50% to 80% decrease in the size of the MOHLTC, and a 15%-20% increase in the size of the fourteen LHINs. Who wants to support this plan? The answer: no politicians and no public servants — but lots of people in the delivery system want “local empowerment”.

People tell stories about former Health Minister George Smitherman asking on a weekly basis: “When are we going to downsize at Queen’s Park…when are we going to devolve authority?” However, the Premier’s key healthcare advisor, Dr. Alan Hudson did not much like the LHINs. And the new ADM that they recruited who was responsible for their development, threatened to cut their numbers in half — from 14 to 7 LHINs. So much of the life of our LHINs has been spent being threatened.

It was very sad watching most LHINs crumble under such threats. After 8 years and three generations of CEOs and Board Chairs, the LHINs have managed to survive. Just as in any complex adaptive human system, when you are in a threatening insecure environment, people tend to become very guarded — with all kinds of self-protective behaviors.

I’m not saying there was more dysfunctional behaviors in the LHINs, than among any of the other health system players, but let’s remember that the MOHLTC and the LHINs are both “crown agencies”. They are supposed to be on the same side — working for one master: the government. The public interest. Hello?

While the LHIN-brand has taken a terrible beating — some of which was well deserved — we nevertheless have a number of examples of health system innovation among LHIN Boards and staff. But these were newly-formed and quite fragile organizational entities that everyone loved to hate. So when innovation does happen, it is mostly ignored.

The problem was that the McGuinty Government became scandal-plagued by their inner-circle of interconnected friends. Their public defense was that our Health Service Providers ran very poor procurement processes that lacked rigorous bureaucratic controls. “We don’t have an inner-circle problem. We have a procurement process problem”, said the government.

This fear-based environment at Queen’s Park was also hyper-ventilated by the public servants who were determined to avoid being blamed themselves. As a result of all these scandals, there are now lots of good paying jobs in the ever-expanding procurement bureaucracy that has mushroomed over the past five years.

To ensure they could never be blamed, Queen’s Park also developed “worst-practice” Accountability Agreements with each of the LHINs. In these Performance Agreements — imposed by the Ministry — the LHINs are being “held accountable” for outcomes/results over which they have absolutely no control.

For LHINs that are confident, they have simply “signed-off” on their Performance Agreements, and set out to “manage” the Ministry — an activity that can require shifting resources intended for local planning processes, to the more complex task of “managing Queen’s Park”. But it is necessary to “feed the beast” to keep them happy, and keep the LHIN safe.

Then of course is the big motivational issue of: who does Queen’s Park like best? The CCACs? The hospitals? The doctors? The LHINs? These are important contests, aren’t they?

Yes they are. Many thousands of hours of senior executive time is invested in government/LHIN/association politics. Some CEOs invest up to twenty-five to thirty percent of their time in “spin-doctoring” up — which often robs the organization of their Chief Executive’s attention.

In LHINs that are more fearful of Queen’s Park, than committed to their community’s IHSP, the dynamics of “blame avoidance” tend to be at play. LHINs that feel threatened by their Performance Agreements are most likely to extend the practice, and hold their HSPs accountable for outcomes over which they also no no control.

The Legislative Review Committee still has some hearings left. I hope they would invest some time uncovering why the government never implemented their own legislation after the former Minister, George Smitherman, and the three key ADMs who designed the “LHIN system”, left the Ministry.

When LHINs were first established, the concern was: will LHINs become an “unnecessary layer of bureaucracy”? But after spending hundreds of millions setting up fourteen LHINs, the current government clearly changed their minds based on the input of their civil servants. Shouldn’t that be what this so-called “review” should be about?

Here are a few questions that I suggest the Legislative Review Committee ask:

Why did the MOHLTC not devolve authority to the LHINs — as outlined in the Legislation?

Did the MOHLTC create written explanations over the past several years for why they have not devolved authority year-over-year, for eight years?

Inside experts peg the downsizing of the MOHLTC at between 50% and 80% — if the legislation’s planned devolution actually took place. There would also be some growth in the LHINs. What was the MOHLTC’s estimate of what devolution would produce — in terms of job loss at Queen’s Park, and some job gains and skills upgrading at the LHINs?

After Minister Smitherman and the ADMs who shaped the LHIN legislation had left MOHLTC, the bureaucracy would have produced written briefings for the next two Ministers with their best advice on the issue of “devolving authority/spending power” to the LHINs. What reasons were given in these briefings for ignoring the legislation passed by our Legislature into law?

When the LHIN legislation passed, MOHLTC had 5 Assistant Deputy Ministers. After introducing the devolved model, the MOHLTC had grown 13 ADMs, 2 Associate Deputies and a Deputy Minister. Should the Legislative Committee attempt to discover how the “devolved model” approved by the Legislature produced such growth at the MOHLTC?

While the NDP and the Tories have made it clear that they would get rid of the existing LHINs, where would these parties stand if local communities had actually been empowered — through their LHIN — to decide on the allocation of resources among the HSPs in their community? Do they want to get rid of what they believe has become an “unnecessary layer of bureaucracy” at the local level, or do they want to down-size Queen’s Park — and enable the LHINs to actually function as they were originally designed?

If our emerging economic realities require our healthcare system to do more, better for less; then the question becomes: who is best positioned to decide on the allocation of healthcare resources locally, the MOHLTC in each of their fragmented Ministry silos; or, in a strengthened, better resourced, re-vitalized, re-skilled and community-led LHIN — with an expanded staff to support the devolved role and function?

Maybe that should be the Election Healthcare Issue for the three political parties: if you are elected, who will redesign our local healthcare systems — Queen’s Park, or local communities?

How will they fund the expansion of community support services? By shifting resources in the delivery system; by increasing taxes, or, as some interest groups suggest: by “means-tested private pay/co-payments/user fees?”

When the LHINs were first set up, the Opposition Parties and the health critics said they feared the LHINs would become fourteen “mini-MOHLTCs”. Studies were generated by Queen’s Park to argue that everything needed to be the same, not different. “Consistency” was the buzz-word du jour. Today, the LHINs that have evolved are the product of the political and bureaucratic pressures to which they have been subjected over the past eight years. After being blasted in this political furnace, and ignoring the original design of the “LHIN system”. The results are not pretty. Indeed, while there are some innovative and creative LHINs, many are not. Many are the product of fear and anxiety.

If the Legislative Review Committeeshifts its focus to “system design”, they should seek to discover why the LHINs are not the authority for all primary care. You can’t be calling for integrated care, and also be the root cause of a fragmented system. The Committee should also seek to discover why LHINs don’t have a major mandate on population health initiatives and working with effective health equity planning tools.

Since the behavior of politicians in the legislature — and in the media — set a major part of the “tone” in our healthcare system, the Committee ought to ask people if they think the behavior of Queen’s Park politicians has been helpful, or harmful to the system’s development.

The Committee should also seek to discover who — if anybody — is planning the new “transformed healthcare system”. Where is the shift from acute care to community care is being planned? Is it rhetoric, or does someone — anyone — have an actual plan for transforming the system? Does anybody think government ought to have a plan, or should we bring in another Don Drummond and ignore their “wise persons’ report”?

If Legislative Committee needs to be sensitive to the fact that nobody wants to just come out and speak the “whole truth” publically, the LHIN Boards need to be able to “speak truth to power” in their regular meetings with the Minister. The LHIN CEOs each work for their Boards. This is how the system works in practice.

Leadership surveys @ TedBall.com over the past year reveal that both governance and managerial leaders seem to feel a sense of “pending chaos” about Ontario’s health system transformation. The first question people ask is: do the bosses really know what they are doing?

What we need most from our governance and managerial leaders in these uncertain times is resilience, confidence and optimism. I hope you find that most of my blogs try to model that — while telling most of the “whole truth”.

In Positive Organizational Scholarship, Sutcliffe and Vogus define resilience as “the ability to flourish and thrive amid adverse conditions when rigidity might be expected.” What we know from their research is that organizations with positive work relationships are more resilient – recovering more quickly from external threats and internal implosions. However, while positive relationships are a key to success, the research tells us that to succeed in a transformation, there must be alignment at the top.

The Balanced Scorecard Collaborative who have studied best practices since the early 1990’s say that the most common reason for strategy execution failure is a “lack of commitment/ alignment at the top” – that is, among the executive leadership of the organization; or, in the case of a Health Link, it would be the CEOs and senior staff of the partners. In the healthcare sector, this also requires the leadership to shift from reactive “crisis management”, to proactive strategy development, and to strategy implementation/strategy execution.

How can a CEO create such a fundamental shift in the thinking and behavior of their top management? How can middle managers “add-value” to those who actually delivery the services? Professional leadership coaches and change management scholars would emphatically say that it must start with a commitment by the CEO to model “change” and “learning” themselves.

Experience tells us that when a Board is encouraging their CEO to find innovative solutions, success rates skyrocket. When CEOs and managers tap into the collective intelligence of their organizations, there is a surge of innovative solutions to long-standing problems.

Brain research over the past few years has produced critically important information for people whose function is to provide leadership. We now know that the moment our brain registers ambiguity or confusion, it alters the chemicals in the part of our brain called the anterior cingulated cortex and makes us crave certainty.

David Rock in “Managing with the Brain in Mind” tells us that “not knowing what will happen next can be profoundly debilitating because it requires extra neural energy. This diminishes memory and undermines performance.” However, the key information for CEO’s and their change journey design team is that according to the research “mild uncertainty attracts interest and attention.” He points out that “new and challenging situations create a mild threat response, increasing levels of adrenalin and dopamine just enough to spark curiosity and energize people to solve problems.”

In my experience, leaders who create the perception that success is attainable — within the chaos — because the organization is smart and capable — always succeed. Also showing long-range plans (like an 18-36 month Transformation Journey Map, or a strategy execution process like the Strategy Management System’s 8-box model) tends to calm people because they then sense that there is actually a real commitment to the transformation process. In the past, many people have experienced hopeful boasts by their CEO, by the LHIN, or by the Minister — but then nothing much happened.

David Rock says “although it’s highly unlikely everything will go as planned, people function better because the project now seems less ambiguous.” However, it is about getting the right balance between ambiguity and certainty. In their study of how Japanese companies create the dynamics of innovation, Nonaka and Takeuchi say “ambiguity can prove useful at times as a source of a sense of alternate meanings and a fresh way of thinking about things.” They say: “new knowledge is born out of chaos.”

As in the balanced scorecard strategy development process, or in the patient experience design storyboarding process, or in the Health Link development process, organizational knowledge creation is a continuous and dynamic interaction between tacit and explicit knowledge.

We talk about the “Learning Organization” approach being top-down & bottom-up. However, in the full real-world roll-out, the process is very much a middle-up-down-sideways process.

The strategic decision to become a Learning Organization, or for a Health Link Partnership Group to become an Intentional Learning Community, means that CEOs need to learn how they can lead and manage such an evolved and inter-connected organization. This can be a very different style of management than the current norm in the healthcare sector. CEOs who want to have a more leveraged impact need to learn more about how they can be developmental coaches and learningfacilitators. They need to determine how they will personally model leaning, growth and change during the transformation journey.

Old ideas about “bosses” won’t work in our context. Today we need CEOs to be teachers, facilitators and role models. When everyone understands that the leaders are deeply committed to the struggle to become a “learning organization” that learns from its “best mistakes”, people always become less anxious, more open to exploring change… more open to learning.

That often means “learning-how-to-learn”. It requires an understanding of adult learning methodologies/ learning styles, and developing their own capacity to be developmental facilitators and coaches to others. So here, once again, is the need for a balanced perspective between a journey that is designed to support the development of all these essential “soft” skills – while putting in place the rigorous systems, structures and processes that will enable the organization to achieve these bottom-line results.

CEO’s and senior teams that are pathologically focused on the bottom-line results — but fail to address the “soft-side” to mobilize the humans — will fail, every time. However, some will continue to thrive on the basis of results-oriented language that is supported, at best, with incremental gains. All of the literature in this area indicates the critical importance of “the leader” in these major transformation efforts.

While external coaches and facilitators and internal senior managers and facilitators can very often “add value” to such a process, it is essential that the transformation process be led by the CEO. Others can help, but unless the CEO leads it, the gains will only be incremental, the pace will be very slow, and the changes are not likely to be sustainable.

The challenge for senior managers is how they will change their relationships with their direct reports. How do you stop being a “boss”, and start being a coach, guide, mentor and learning facilitator?

“Oooh! The soft, mushy, human stuff and the ‘vision thing’ again,” the cynics will say. But while many of our best performing healthcare organizations do have some fancy IT support, their transformation is succeeding because the people in the system think differently and act differently – in contrast to just “doing things differently”, but “thinking the same way.” What is most common among the top performing healthcare organizations is that they are transforming towards the learning organization model of staff empowerment and continuous improvement.

Organizations that produce superior results with Balanced Scorecards, best practice Accountability Agreements, and collective intelligence tools like Kaizen and Storyboarding, are those where the middle managers have transformed themselves from command and control in organizational silos, to a new emphasis on developmental facilitation for integrated, cross-functional high-performance teams. Gosh, even our Minister has transformed herself into a learning facilitator — instead of just being ministerial, and “announcing” her thoughts she comes to Longwood’s Breakfast with the Chiefs Program and facilitates.

This new skill for developmental facilitation is different from basic facilitation. However, experience tells us that middle managers will not transform until and unless their bosses have authentically transformed as well – and are themselves modeling the thinking and behavior that middle managers are expected to exhibit for front-line workers. The evidence tells us that the senior management team members behavior is the single most important factor that will drive change.

This is a major challenge for CEOs: how to develop the capacity of their senior and middle managers to be highly strategic and capable of leading and managing others through a transformative learning experience. While IDEAS from Utah may provide a few more tools, CEOs can’t contract out their role as teacher/knowledge facilitator to Queen’s Park. From the CEO’s perspective, since their own personal success is completely dependent upon the success of each of their direct reports, they clearly have a major stake in seeing that each of their senior managers will be successful at achieving the outcomes for which they are accountable.

After all, when the CEO’s direct reports are successful at achieving their outcomes, the CEO is, by definition, successful. And, when the CEO is successful at achieving a balance of outcomes – everybody wins. Does that sound like a place you would like to work?

FORWARD THIS BLOG TO COLLEAGUES WHO BELIEVE THAT THERE IS LEVERAGE IN THE SOFT, MUSHY, HUMAN STUFF — AND IN THE DAMN “VISION THING”.

“Accountability” is a word that is loaded with meanings that strike fear in the heart and soul of our health system’s leaders and followers. That’s because it has come to mean: “Who is to blame?”; and, “How should they be punished?”

E-health, Ornge and other scandals has everyone focused on blame-avoidance, blame-sifting, gaming, cover-ups, in-fighting, defensive behaviors, anti-leaning dynamics and the cause of even further dysfunction in a system already diagnosed as among the “least healthy work environments in the country.”

The question is: how has the system responded to the rigid rules and controls that have been imposed from the top? Did it improve the system, or did it produce gaming and compliance role-playing? Have system leaders just blindly gone along with this whole “blame culture” that has been nurtured by Queen’s Park to deflect blame from the inner circle of connected operators? Are there any leaders who are prepared to speak-the-truth, or is everyone afraid of some unknown and unspeakable horror? Is anyone prepared for true accountability?

Accountability is very different than blaming — which means “to find fault with, to censure, revile, reproach”. Blaming is an emotional process that seeks to discredit the blamed.

Marilyn Paul, a scholar in the field of organizational accountability says that a blaming culture causes organizations to become dysfunctional because “where inquiry tends to cease, and the desire to understand the whole problem diminishes.” Paul says that “accountability creates conditions for ongoing constructive conversations in which our awareness of current reality is sharpened, and in which we work to seek root causes, understand the system better, and identify new actions.”

If we accepted this best practice notion of “mutuality”, it would require a significant paradigm shift for a healthcare system that is currently rooted in hierarchical, command-and-control systems, structures and processes. Unfortunately, while we talk about following best practices, we don’t — including on this key topic of “accountability“.

Marilyn Paul says that “holding people accountable should only be done in the context of clearly defined outcomes. Outcomes must be understood and adjusted regularly to reflect new realities. Not only must everyone understand what is expected of them and why, they must also have the necessary resources, conditions and skills to achieve the outcomes for which they are being held accountable.”

Governance Boards need to ask: are you following best practices when you “hold the CEO accountable”? The MOHLTC needs to test the design of the current Performance Agreement Process with each LHIN against the six principles for accountability design.

At the operational level, governance and managerial leaders need to ensure that there is a best practice Accountability Process that is designed to mobilize the support required to make each person successful at achieving the outcomes embedded in three places: in their organization’s Balanced Scorecard; in their Health Link Business Plan; and, in their LHIN’s Integrated Health Service Plan.

From “best practices”, here are the SIX PRINCIPLES OF ACCOUNTABILITY:

1. You Can’t Be Accountable For Anything Over Which You Have No Control.

A best practice Accountability Agreement must be a “fair business bargain”. It is a personal promise to achieve measurable results. But a person can’t keep their promise if circumstances beyond their control change.

That makes sense, doesn’t it? If a CEO is being held accountable by their Board for improving staff/physician moral, and their provincial government is engaged in highly emotional disputes with unions and physician organizations, how can the CEO be held accountable for the results that such an atmosphere will produce?

However, the CEO should certainly be accountable for demonstrating improved outcomes with their own organization’s unions, staff and physicians that they are able to achieve from the processes that they put in place to achieve their measurable results locally.

If a manager is being held accountable for an outcome that can only be achieved if a certain barrier is removed – like the lack of a skills development program, or the lack of equipment or technology – and nobody removes the barrier, why should they be expected to be accountable?

If a Health Link lead is being “held accountable” for the outcomes promised in their Health Link Partnership’sBusiness Plan, what happens if the cause of the sub-optimal performance is the lack of an integrated set of accountabilities among the other partners? How can they possibly deliver on their promise — if they are not given the level of support from their partners that they require to succeed?

Best practice Accountability Agreements list the “supports required” to achieve the outcomes for which a person is willingly accountable. If they don’t get the support they need, they can’t be held accountable. It’s that simple.

That’s where this concept of “mutual accountabilities” comes into play.

At the operating level, a manager with an Accountability Agreement must be able to hold his or her boss accountablefor providing the supports they mutually agree arerequired to successfully achieve their outcomes. At the LHIN-level, a Health Service Provider must be able to hold the LHIN accountable for the supports they require to succeed. Same at the Health Link level.

An Accountability Agreement is therefore a tool for people to mobilize the support they need to make them successful. It’s a manager’s, or an organization’s best friend, not their worst enemy!

Between the LHINs and each of the agencies and institutions they fund, there also needs to be an explicit and “fair business bargain” designed as an Accountability Agreement.

What are the high-level outcomes — results — that the province and a local LHIN will hold a Health Service Provider Board accountable for, and, what “supports required” can a HSP Board hold their LHIN, and the Ministry of Health, accountable for providing? This is the best practice principle of mutual accountabilities.

While many would accept that such thinking is perfectly reasonable and fair, our traditional cultures in hospitals, CCACs, community health and support agencies, and the MOHLTC are still very much stuck in the “blame-game”. Indeed, it is ingrained in our culture – how we think and behave.

Nobody ever went after the people who benefitted from past scandals. Indeed, most are still around and thriving. But in the midst of the scandals, Queen’s Park proclaimed that the problems were not caused by an inner-circle of connected friends, but by a lack of a rigorous RFP system.

So instead of going after members of the inner-circle, the government wagged its finger, warning all HSPs to rigorously follow the newly-created rules, templates and processes which will enable the system to pinpoint who we should all blame and shame. This is a worst-practice design flaw that leads to severe dysfunction.

When we redesign accountability to fit with best practices, we’ll end the “blame-game” – and, we will shift our culture towards the way true learning organizations think and behave.

In an environment that is so much about “control” and “risk management”, the people who reach the top positions tend to be people who thrive in command-and-control environments. This is in stark contrast to environments that are all about “creativity” and “innovation”. The top bosses in such organizations model the behaviors of innovative and creative managers.

While there are pockets of innovation everywhere across our healthcare delivery system (perhaps 20% to 30%), most HSPs (70% to 80%) are zealously compliant, and very fearful of authority. They focus mostly on “risk management” and “blame-avoidance”, not “creativity”, “innovation”, “learning”, and “continuous improvement”.

If we spent as much time, energy and creativity on quality, safety and the patient experience, as we do on blame-avoidance, we would have a much better system.

Unfortunately, the MOHLTC has simply ignored the first principle of accountability in the design of their Performance Agreements with each of the fourteen LHINs. Today, the Ministry holds each LHIN accountable for outcomes over which they have absolutely no control.

Despite this “worst practice” behavior by the MOHLTC, the fourteen LHINs simply accept this unfair/worst practice as part of their lot in life. The LHINs who just “sign off” on their agreement, and simply set out to manage the government relationship, behave well. The LHINs that are frightened by their Performance Agreement, usually pass on their fear to their HSPs — with equally unfair Accountability Agreements. This is the “abuse syndrome”.

Rather than focusing on making real improvements, people under pressure tend to “game the numbers”. Indeed, “gaming the numbers” is a very common defensive routine in blame-oriented environments.

The second key principle for best practice approaches to accountability:

2. Accountability For Outcomes Means That Activities/Efforts And Processes Are Not Enough.

Think of the mindset shift required here. Our health care system is characterized by a complex set of rigid bureaucratic processes designed in separate Ministry and government silos holding very different assumptions about reality, and about “what works”.

Unfortunately, bureaucratic processes create jobs with turf boundaries to protect – at the operating level of the system, and, between the public servants and the organizations that receive funding. It also creates turf boundaries between service providers and the separate silos within the Ministry of Health.

The truth is, our fragmented health care system is the product of the individual self-interests of the isolated silos within our Ministry of Health. Fragmentation is actually designed into the DNA of the system. Overseeing all the Ministry silos over the past year is the newly-formed Transformation Secretariat thathas a mandateto create 80localintegrated healthcare delivery systems across our fourteen LHINs.

While each Health Link must have an operational business plan, there are currently no plans for how governance and accountability will work in the transformed system. Whoops! That seems to be a fundamental design flaw.

While there is lots of talk about “transformation”, the actual focus of our healthcare system today — in the post E-health/Ornge era — is on the rules, regulations and bureaucratic processes developed in the top-heavy silos at Queen’s Park.

Best practices would suggest that “holding people accountable” should only be done in the context of clearly defined outcomes or results. These outcomes must be understood and adjusted regularly to reflect new realities as they emerge in a constantly changing and chaotic environment.

Not only must everyone understand what is expected of them and why, they must also have the necessary resources, conditions and skills to achieve the outcomes for which they are being held accountable. Is that not a reasonable and “fair business bargain?”

In a best practice accountability process, no one is given points for “following the process”. The only thing that counts is getting the results. If the process design does not produce the results required, we need to change the process. Better yet, we need to design processes that are focused on achieving the results that are required – right from the start!

So let’s start by honestly reflecting on the unintended consequences of the way we currently define and practice accountability in the healthcare system – and in the public sector generally. Is the accountability process really designed to achieve the outcomes that we all want to achieve, or, are the MOHLTC processes just simply designed to exert “control” by the people with authority, and to ensure that blame can be placed elsewhere?

At the operating level of our health care services delivery system, we need to ask ourselves: what are we in management and governance going to do to provide the practical supports required to make our people successful? At the LHIN-level, and Health Link governance-level, the focused question is: how can you ensure that individual Health Service Providers, and the local Health Link partnerships are successful?

In my view, a system that is focused on “accountability for outcomes” (rather than MOHLTC’s focus on process) would have the best chance of finally shifting our traditional pattern of spending more and more resources to produce poorer results. This needs to be a “fair business bargain“.

This principle would require another paradigm shift for the health sector: the principle is about the reality of balancing empowerment and accountability. Not the empty rhetoric that has contributed to the growing cynicism of our front-line health care providers — but real empowerment, and accountability.

While the health care sector is clearly part of the knowledge economy, many of us continue to live with industrial-age assumptions about the “need for command and control”, and the need for micro-management by Queen’s Park. These are the folks who think “fewer is better”, rather than adopting the “benefits of bio-diversity” in healthy complex adaptive systems.

The assumption in other modern knowledge-based industries that rely on skilled professionals is that the solutions to their most complex and perplexing problems are within the hearts and minds of the people who work in the system.

Smart organizations that are thriving in the knowledge economy invest between 1% and 5% of their payroll budgets on developing the skills of their people to work in high performance teams solving organizational problems and dilemmas by tapping into the collective intelligence of the people in their system.

Is our health care system now prepared to invest in our own IQ — at the service delivery level, with intact teams who are “learning by doing” on transformation projects in their organization, as well as across the continuum-of-care among the Health Link partners?

One of the more interesting shifts that has taken place in the system over the past eight years is the “role of the CEO”. While we were not too good at holding bad CEOs accountable we provided an environment where CEOs were liberated to be innovative.

Not anymore. To be innovative in a totally risk-averse environment is just stupid. So there are very few examples of true innovation from CEOs anymore. Maybe 10% -15% are “leading-edge” — half of what it used to be. If this is to change, the risk-averse blame environment has to change.

Everyone acknowledges that the post-scandal rules have gone “way overboard”, and need to be brought into balance. We need to rid ourselves of rules and processes that scream: “No innovation!“

To restore a sense of “safety”, the existing culture must change.

Are we prepared – at the governmental, Board and managerial levels to stop blaming and replace the rhetoric about being “learning organizations” and “best practices”, with the reality of learning organizations and following “best practices” – by having a real balance of empowerment and accountability, and by investing in the skills of our people?

The fourth best practice principle on accountability design is:

4. Accountability Must Be Dynamic: Outcomes And Targets Change As Circumstances Change.

While most people would agree that this seems perfectly reasonable, the existing rigid bureaucratic culture of health care – from the Premier on down to the front-line care provider – is about “inflexibility”, and “rigid rules” and “approved templates”.

In the existing system, we are given every incentive to focus primarily on the process, rather than the outcomes. We tell our people that they need to be innovative, and that we should “learn from our best mistakes”, and then maintain the same old systems, structures and process that account for 93% of the reasons why our results are sub-optimal! Compliance is the outcome from this system based on fear.

We also need to be flexible as we learn and improve. Health Links need to be designed with “Shared Accountabilities” to promote better communication and teamwork between the various Health Service Providers.

Without a flexible learning approach, people will feel fearful, fearful of being blamed.

The emphasis in governmental communications has been to make a big fuss over the “early adopters” — special people who have been admitted to some sort of special inner circle. All talk of “accountability for outcomes” is avoided in an environment that has been made fearful by the same people who now speak glowingly about the “early adopters”.

Deming told us: “first, drive out fear”. Yet fear and anxiety are the dominant emotions that are driving our health care system today. Best practice Accountability Agreements are flexible. When circumstances change, accountabilities change. The focus is on what needs to be done to ensure that a person is successful.

That is how Learning Organizations function. The bosses are “in service to”, rather than “in control of” those who work for them. As circumstances change, sometimes it is possible to achieve gains that are double the original target. Sometimes the circumstances that emerge require downsizing the target, or even shifting the goal altogether.

The fifth key principle for accountability system design is:

5. Accountability And Stewardship For The Organization Belongs To Every Employee.

Management guru Tom Peters has said that health care systems, structures and processes are the most complex organizational designs ever conceived by humans. But most of our core design assumptions are very much rooted in the old industrial model.

Re-engineering and lean thinking are two techniques borrowed from the manufacturing sector, rather than designed for a complex adaptive system like healthcare.

Systems thinking, chaos theory and quantum physics have all contributed greatly to our emerging understanding of the health care sector as a complex adaptive system. Each part of the system impacts on the performance of the other parts of the system. We know that.

Despite the fact that all parts of the health care system are inter-connected, we’ve organized ourselves into rigid silos and departments which we attempt to “manage” through traditional bureaucratic control mechanisms — where we solve issues within each silo — often without any apparent concern about its impact on the other parts of the system.

Best practice accountability processes include integrating the agreements cross-functionally — across the organization, and, in a Health Link, across the healthcare delivery system. That way, people will truly understand how their actions impact on others; and why we need to ensure that we are working synergistically together within our organizations, and with all parts of the system.

With the introduction of Health Links as local integrated delivery systems at a sub-LHIN level, we have created another important set of accountabilities for the outcomes promised in each Health Link Partnership’s Approved Business Plan.

The sixth and final principle for designing accountability systems is:

6. Accountability Is Meaningless Without Fair And Appropriate Consequences.

For all the fear and anxiety that our existing hierarchical, command-and-control accountability processes produce in people, the truth is that there really isn’t much of a focus on the actual consequences — just the “threat” that maybe something bad could happen.

In their book, Accountability: Getting a Grip on Results authors Klatt, Murphy and Irvine point out that “accountability is not about assigning after-the-fact blame. Rather, it’s about providing before the fact incentive for success, and room for decision-making, risk-taking and growth.”

They state that “consequences may be positive or negative, but either way they need to be fair. They are not punishing or under-handed. Finding out what went wrong in a situation is essential for preventing the recurrence of problems.”

But, for the most part, there are not many real “consequences”. Just fear. Indeed, our healthcare system is being run by very high-priced managers, a critical mass of whom are primarily motivated by fear.

In a best practice accountability development process at the Organizational-Level, managers throughout an organization need to think through the outcomes in their organization’s that they should be accountable for; the supports they need to be successful; and, what the consequences will be on their organization, their unit and themselves if they fail — or, if they surpass the targets agreed to.

At the LHIN-Level, each HSP CEO needs to determine what part of the region’s Integrated Health Service Plan their organization ought to be accountable to the LHIN for achieving. So, in addition to being accountable to their Board for their organizational outcomes, CEOs would also be accountable to their Board for IHSP outcomes as well. At the Health Link-Level, the accountable “lead CEO” needs Shared Accountability Agreements that enable each of the partners — at the CEO level — to understand what part of “the whole” they are accountable for achieving.

When these processes are truly designed and aligned with a learning and continuous improvement focus, they work. They don’t work in bureaucratic, anti-learning and blame-avoidance environments.

That’s why Boards and CEOs need to rethink how they practice accountability. This is a key leverage point which can cause the redesign of the delivery system. Boards and CEOs need to be aligned on both the “outcomes” and “supports required” for a “fair business bargain” between the Board and the CEO.

FORWARD THIS BLOG TO COLLEAGUES WHO YOU THINK MIGHT WANT A BEST PRACTICE ACCOUNTABILITY SYSTEM THAT MOBILIZES THE SUPPORT THEY NEED IN ORDER TO SUCCESSFULLY ACHIEVE THE OUTCOMES FOR WHICH THEY ARE ACCOUNTABLE.

Following on the heels of last year’s craze over Generative Governance, there is now a new and improved “flavor-of-the-month” for healthcare boards, called, “Collaborative Governance“. The good news is, you can do both — at the same time.

For the most part, the people currently talking up the concept of “Collaborative Governance” really only mean that collaboration is a “good thing”. It’s a nice value, rather than an aligned pragmatic system design for governance. In this simple worldview, collaboration is “good” and, as such, ought to be practiced.

The people urging others to think about, or practice the values of “Collaborative Governance”, tend to be focused on the emerging LHIN-level, and the Health Link-level, governance issues. At the Health Link level, we now have 37 groups of local health service providers who have come together to create a Health Link based on an agreed-upon, and approved, Health Link Business Plan.

The Boards of all HSPs who have joined a Health Link — perhaps 400 to 500 Boards –are now accountable to their Local Health Integration Network for the outcomes promised in their approved Health Link Business Plan. The “lead organization” in each Health Link is formally accountable to the LHIN for achieving the outcomes promised in their approved plan. The partners need to share accountabilities to cover off the “lead partner’s” accountabilities. But many HSP Boards don’t seem to be too aware of these developments and their new accountabilities.

While there are some examples of Health Link Partners’ Boards & Senior Managers seeking to get aligned on a “Shared Vision” that would enable them to succeed, and to begin to transform their existing system, observers report that many Health Links have become a simple “add-on program” (dealing with the top 5% of health system users) to the same old/same old system — with the same old/same old silos. They say that there is nothing that is “transformational” that is going on in these Health Links and that most governing Boards don’t know much about their new system commitments.

If that’s the case in some Health Links, people should re-read the memo from the government on health system transformation. Health Links are a new structure to integrate services at the local level — starting with the 5% high users. But collaboration among HSPs and Health Links are here to stay — indeed, there will soon be 80 of them. Health Links are not an “add on” program. They are intended to be vehicles for transformation and integration. The Minister calls them “silo-busters”.

But the concept of “Collaborative Governance” must become more than just a “good intention” and a “nice value”, it must be intentionally designed and aligned to actually work to create collaboration at the CEO/Management/and clinical levels. Collaborative Governance needs to be designed to be an antidote to “silo governance”. It enables silos to be part of the network system. It is intended as a force for integration — if the Boards of Health Links partners would ever meet together to ask the “wicked” and “probing questions” on behalf of the community.

Health service providers who are members of a Health Link now have two key system-level sets of outcomes for which they share responsibility and accountability. At the LHIN-level, they have their Integrated Health Service Plan; and at the Health Link-level, they have the approved Business Plan — with the agreed-upon outcomes.

When HSPs were only silos, boards only held their CEO’s accountable for outcomes in their silo. Today, a major feature of Collaborative Governance ought to be that while boards exist to ensure good management in their silo, as Health Link Partners, and as members in a common LHIN, they are equally and mutually accountable for improved outcomes in their local healthcare services delivery system.

So in the future, Boards would hold their CEO accountable for both system-level, and silo-level outcomes. That’s the leverage point for Collaborative Governance: system & silo accountabilities. It’s the traction that makes integration actually occur at the Health Link level. So, it needs to be much more than a good intention.

Many governance Boards use management’s Balanced Scorecard Outcomes as the measures they use to hold the CEO accountable for their silo-level outcomes. They can use the Integrated Health Service Plan, and their Health Link Business Plan, as two key reference points for placing equal value on their CEO’s system-level efforts.

The “lead” Health Link partner organization has been entrusted with one million dollars of taxpayers’ funding to support the development of the partners’ action plan. Some of the more strategic CEO-led Health Links (vs. the more operational ones), will be developing Health Link Balanced Scorecards that spell out the “cause-and-effect linkages” between the Customer/Patient/Client outcomes; the Financial outcomes, the Process outcomes, and the Learning & Growth outcomes in their scorecard.

The advent of Health Links as formal partnerships, with formal accountabilities, ought to trigger the governance boards of the Health Link Partners to get together — perhaps three or four times per year — to review the progress being made together by “the partners” in the network.

By bringing the Health Links Partners Governance Boards together to review their local delivery system’s progress; and to explore how the partners could transform the patient experience as they travel across the continuum-of-care; communities, through these boards, would be able to hold “stewardship” for the local health services delivery system’s transformation journey.

As “stewards” for the well-being of their community, our governance Boards need to stretch their minds ahead to 2015 and beyond. They need to understand that there will in fact be fewer resources available for healthcare services. There will also be a pressing need to re-allocate resources within the existing system to meet the emerging needs of each unique community.

The challenge for Health Link Partner Boards and their CEOs, is how quickly they can prepare for major transformational change over the next two years — while funding remains somewhat stable. In the Fall Economic Statement, our minority government put the “day-of-reckoning” off until perhaps the Spring of 2015, but it could be sooner.

So, now would be a good time for Health Link Governance Partners’ conversation about Collaborative Governance design — before the financial crunch comes. At the bottom of this blog is the framework of the Strategic Alignment Model — a best practice systems thinking design tool (in the shape of tetrahedron) for aligning complex adaptive human systems.

You need to start with Mission & Vision. Why do you exist, what is your purpose? And, what are you seeking to become — your shared vision for the future?

I really like mindmapping techniques for this purpose because these day-long visioning exercises get people connected together as people. They are taken out of their “normal comfort zone”, and engage in exciting and enjoyable group mindmapping exercises.

Once the Boards and Senior managers of a Health Link have engaged in mindmapping that has aligned them on a Shared Vision, the Health Link Partner CEOs can then develop a Health Link Scorecard that sets out the “cause-and-effect” relationships for their individual Board’s approval of the aligned strategic directions.

If Health Links are to become the “transformational” vehicle that Queen’s Park believes they are, the partner CEOs and senior managers need to be liberated by the governors to develop the strategy and a plan for aligning the structures, culture and skills of the partnering organizations.

Collaborative Governance design could also include an aligned structure for regular quarterly meetings of Health Link Board Chairs/Vice Chairs (as well as the LHIN’s Board Chairs/Vice Chairs) in order to review the Health Link Scorecard, and to engage in generative dialogues on high-level strategic directions for the Health Links Partnership.

If partner Boards within a Health Link met quarterly, the CEOs would be able to demonstrate improved collaborative outcomes at each meeting of the governors. While the CEOs are accountable for outcomes, Boards can “add value” on behalf of their communities. How?

Of the three governance modes of Strategic/Fiduciary and Generative, the Collaborative Governance Partners’ Council needs to focus primarily on being “generative“. On behalf of the “owners” of our healthcare delivery system, they need to invest four days per year asking wicked and probing questions that will help management uncover the strategic directions required to achieve the vision for a more integrated delivery system, that improves the patient experience, and achieves the goal of improved health status of the population served.

Health Links need to become learning communities, and the Boards need to play a role in facilitating learning, in their organizations, and across the sector.

STRUCTURE, as you can see on the Strategic Alignment Model at the bottom of this blog, structure includes: design, decision-making and accountability, information systems, rewards/incentives and strategic budgeting.

An organization’s design includes: what it does (its functional design); who does what (its structural design); and, how work is done (work process design).

It includes strategic budgeting: if the Health Link partnersdon’t align their budgets with the Health Link promised outcomes, the outcomes won’t be achieved. Boards of Health Link partnerships should ask to see the allocation of resources to support their Health Link commitments.

Health Link Partner Boards ought to be exploring how the components of structure, culture and skills need to be aligned to achieve the results outlined in the Health Link Level Scorecard. For example, Accountability Design. If each Board holds their CEOaccountable for both silo and system outcomes, would the philosophical concept of “integration” not get a major practical boost?

Structure also includes the design of linked and integrated best practice accountability agreement processes that enable organizations to truly collaborat. Also it includes information systems that connect the service delivery system together as a patient-centred system.

While “structure” is like the DNA of the system design (whatever you design into the system, produces the outcome); culture, which is about “thinking & behavior”, is said to “eat strategy for lunch”. Culture is at the base of the Strategic Alignment Model.

CULTURE at the Health Link-Level, isabout the thinking and behavior of front-line clinicians across the continuum-of-care. Are clinicians focused on the needs of the patient, not the “turf” of their silo?

A major part of culture is the “values practiced” on a day-to-day basis — not the official list of “values“, but the way people actually treat one another in their silo organizations, and as colleagues across the continuum-of-care in service to common patients. If the Health Link is to be a collaborative partnership, staff need to address/refresh their “behavioral expectations”, their “rules-of-the-road”, “commitments to one another”, or whatever.

Leadership also plays a huge, huge role in how people think and behave. If the leader is razor-focused on patient-centred care, they will be too. If they are focused more on pay, perks and ego, than on the well-being of everyone, most people will reflect that same attitude and behavior.

At the governance level, Board members need to understand that as healthcare budgets shift and system transformation actually occurs, they need to truly represent the interests of the citizens of each community — as resources are re-allocated to meet shifting community priorities. In Collaborative Governance, they need to be in Stewardship to one another, to their silo, and to their community’s best interests.

Senior team leaders and middle managers have to “walk the talk” — being open-to-learning, learning from our best mistakes, and seeking to discover the organization’s collective intelligence. They also need to practice emotional intelligence.

While culture is an anchor, the key leverage point for success is “Transformation Skills“.

SKILLS required to achieve a fundamental system transformation at the local level need to be developed locally with intact learning teams on real projects. They might start by developing the Organization’s Silo & Local System Scorecards among directors and managers/physicians — rather than just sending people on a course on “Scorecarding For Dummies“, who return with the answer.

The “skills” component of the Strategic Alignment Model ought to be the key leverage point for the speed and depth of an organization’s — or a local system’s — transformation journey. Essential skills for successful transformation include: dialogue, system thinking, team learning, mindmapping, lean thinking, patient experience design storyboarding, and new ways of thinking and behaving for Boards, called “Collaborative Governance“.

While there is lots of talk about the new buzz-word for “Collaborative Governance” — people don’t address the skills required for asking “wicked” and “probing questions”, for which there may be no answers.

Perhaps the best current example of emerging Collaborative Governance in Ontario is at the North Simcoe Muskoka LHIN. To see NSM LHIN Board Chair, Bob Morton’s presentation at the South East LHINCollaborative Governance Workshop this month, click here: Collaborative Governance @ NSM LHIN.

While the slide-deck outlines the logic of NSM’s Care Connections Project, the glue that actually holds their process together is trust, ownership and commitment. Everybody “owns” the future they are creating together in NSM, and therefore brings high levels of “trust”. Trust enables true collaboration, and, with practice, synergy.

It would seem that by the simple act of holding meetings between the LHIN Board Chair and the HSP Chairs in each of their five Health Link Partnerships, creates a“governance community” who truly care about the well-being of their community, and whose common goal is the successful achievement of the outcomes promised in the Business Plan.

Beyond the Health Link level — where the focus on is integration and collaboration at the clinician level — is the larger community defined by the LHIN’s boundaries. At this level, boards and senior managers of Health Service Providers need to focus on their high-level Integrated Health Service Plan. In a Collaborative Governance Model, they too could meet three or four times per year as the HSP governors to monitor progress, and to explore potential leveraged actions that would propel the whole system forward — the wonderful world of continuous improvement and strategic learning.

So, as outlined below on the Strategic Alignment Model, when Boards and Senior Managers are aligned on their Health Link’sVision & Mission; and, are clear on the Customer and Financial Outcomes that will be achieved — as well as on the Strategic Themesin their scorecard — they can develop and implement aligned Structures, develop the Skills required, and shift the Culture (thinking and behavior) of these organizations to achieve their outcomes and their visions. That’s when transformation occurs.

When Structure, Culture and Skills are aligned to the Strategy, the system will be aligned and synergistic. People and their organizations will surge forward and achieve their vision. If the Health Links Partner Boards are waiting for a memo from the government or from the LHIN on what to do about governing Health Links, they don’t seem to have much to say. So, if you care about the future well being of your community, start meeting.

Health Link Governance Councils can use the tetrahedron model to talk about the structures, skills and culture that will be required to make Collaborative Governance, and these community partnerships, successful.

FORWARD THIS BLOG TO COLLEAGUES INTERESTED IN THE ART & SCIENCE OF ALIGNMENT, AND THE NEED FOR DESIGNING COLLABORATIVE GOVERNANCE FOR HEALTH LINKS AND FOR LHINS.

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What Patients Want

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Patient Experience Design Methodologies

Read about Experience Design Storyboard And Master Process. These truly innovative and effective methodologies are very exciting because they transform the customer/patient /client experience – while significantly improving efficiency and creating more satisfied and engaged healthcare service providers.

Drug Savings

Read a great paper by the extraordinary public servant, Helen Stevenson, who saved $1.5 billion in ODB costs.

Getting To Integration: Command & Control/Emergent Process

Are mergers of small organizations really going to improve our healthcare system? Read this paper in the Public Sector Innovation Journal by Steve Lurie, CMHA, Toronto.

World-Class Resource

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"Ted Ball is a brilliant system thinker, and the best intelligence gathering resource Ontario has. But, what is uniquely exquisite about Ted, is his no non-sense attitude, honesty and integrity to share information generously and widely. Working with Ted is at once - inspiring, stimulating and fun! "

Second curve leaders

Download Designing and Creating Second Curve Healthcare System to discover more about our evolving health system. As you read through what the system will be like over the next three to five years, what do you think are the skills and capabilities required by 2nd Curve Leaders.

Conference Speaker/Retreat Facilitator

Ted Ball is available to address conferences or design retreats for Governance & Management. Give him a call @ 416-581-8814 and explore your unique circumstances.

Warning

Seventy percent of all major change projects fail. While 30% succeed, Quantum’s curriculum reflects the “lessons learned” from the 15% who experience dramatic performance improvements.

This Stuff Works!

“After our two-year investment in capacity-building with Quantum, we had remarkable performance improvements and extraordinary value. Today, our 120 directors, managers and other key leaders are not just more strategic, more aligned and more leveraged, they are also happier, more collegial and more effective as leaders and managers. We are achieving real results with these adult learning technologies and systems thinking tools.”

Bonnie Adamson
Former CEO, North York General Hospital, 2008

Leadership Development

TED BALL has been a coach, guide and mentor to CEOs, Ministers of Health and Executive Directors of community agencies for 20 years. Now, through the Quantum Leadership Institute, you can access Ted’s leadership coaching insights as well as the powerful learning tools from Quantum to prepare you as a 2nd Curve health system leader. Following an assessment and evaluation dialogue with Ted Ball, coachees can either co-design a leadership learning journey to match their unique needs and budget, or determine that other types of investments in their learning & growth would be more appropriate for their goals.

Releasing Human Capacity

“I was so inspired by the coaching model Ted used, I decided to work on a PhD and learn more about human potential and how to release it.”

The Patient Voice Poised To Become The Dominant Driver

Today’s healthcare providers were not trained to provide PCC. They lack the requisite skills, and patient empowerment unsettles them.

The term PCC does not accurately describe what modern patients seek. Patients do not want to be at “the centre” of a healthcare construct; they want to be recognized as full partners in their care, and are speaking about this with an increasingly unified and powerful voice.

Indeed, while economics, demographs, and technological advances will continue to prompt change ‘the patient voice’ is poised to become its dominant driver.”

Learn how to deal more effectively with the Provincial Government. Darwin Kealey & Leonard Domino have advise here: Leonard Domino

We can help with

Measuring What Matters

“There is a clear misalignment between what Canadians value, and how Canadian health system performance is measured and funded. Canadian values have shifted substantially in recent years, towards a preference for greater autonomy and empowerment in managing their health care and management. Canadians' values reflect the desire for a more ‘personalized’ health care system, one that engages every individual patient in a collaborative partnership with health providers, to make decisions that support health, wellness, and quality of life.”
Click here for the executive summary of Measuring What Matters: The Cost vs. Values of Health Care – a must read white paper from the Ivey Centre for Health Innovation.

Heart In Healthcare

Become part of the worldwide movement to re-humanize healthcare. Heart In Healthcare aims to:

• To encourage health workers to reconnect to the heart of their practice
• Allow compassionate caring to rise above institutional rules and limitations
• Create the world’s most inspiring community of health professionals, students, patient advocates and leaders, working together in a worldwide movement to transform healthcare from within.

Big Changes Ahead For Health “System”

Changing Structures Too Expensive/Disruptive

"In Ontario unless there is a compelling political and financial case made to restructure the system, it’s safe to assume that Ontario will not move to formalize health system integration through disbanding organizations and creating regional health authorities. The evidence is overwhelming that not only would it be an extremely expensive proposition – somewhere in the $4-5 billion range to harmonize wages – but it would also be extremely disruptive – taking some 4-5 years to re-establish some form of equilibrium – and could also have a significant negative impact on foundation fundraising on which hospitals in particular are dependent."

Saskatchewan Health Plan Five-Year Outcomes

• There will be a 50% improvement in the number of people surveyed who say, “I can contact my primary healthcare team on my day of choice”.
• There will be a 50% reduction in the age-standardized hospitalization rate for ambulatory care sensitive conditions.
• (by March 31, 2014) All patients have the option to receive necessary surgery within three months.
• Zero surgical infections from clean surgeries.
• No adverse events related to medication errors.
• The healthcare budget increase is less than the increase to provincial revenue growth.
• The healthcare budget is strategically invested in information technology, equipment and facility renewal.
• Zero work place injuries.
• (by March 31, 2022) there will be a 5% decrease in the rate of obese children and youth.
• There will be a 50% reduction in the incidence of communicable disease.
• Seniors will have access to supports that will allow them to age within their own home and progress into other care options as their needs change.
• Patients’ ratings of exceptional overall healthcare experience are in the top 20% of scores internationally.
• There will be a 50% reduction in patient waits from General Practitioner referral to specialist and diagnostic services.
• (by March 31, 2015) all cancer surgeries or treatments are done within the consensus-based timeframes from the time of suspicion or diagnosis of cancer.
• Individuals with severe complex mental health issues with alcohol co-morbidity or acquired brain injury will have access to supportive housing in or near their community.
• No patient will wait for emergency room care (patients seeking non-emergency care will have access to more appropriate care settings).
• Employee engagement provincial average score exceeds 80%.
• Increase physician engagement score by 50%.

Hospital leadership

“Over time, we'll need fewer and fewer hospitals. Boards of those institutions need to just remember that the scope of what they need to do is to be responsible for the health of people, not the preservation of the institutions."

—Clayton ChristiansenDisruptive Innovation

Leadership

“The most important lever for change is modeling the change process for other individuals. This requires that the people at the top engage in the deep change process themselves.”-- Robert E. Quinn
Deep Change

Real Devolution

“A regional health authority, if it’s going to be effective, should be able to determine how money is spent within a region, shifting money from hospitals to community care, from treatment programs to prevention, and so on. This approach worked extremely well in Alberta, so well that it was dismantled because it stripped too much power and control from politicians and policy-makers in the Health Ministry.”-- André Picard
The Globe and Mail

Warning

Seventy percent of all major change projects fail. While 30% succeed, Quantum’s curriculum reflects the “lessons learned” from the 15% who experience dramatic performance improvements.

The Patient-Centred Care Experience:

Like rainbows, examples of patient-centered care are few and far between, but here are some tell-tale signs:
• Providers and patients know each others’ names;
• Patients’ opinions are actively sought, listened to and honored where possible;
• Patients tell you that their doctors and other team members really listened to what they had to say;
• Patients are treated as the most important member of their health care team and taught how they can best contribute to the team’s success;
• Providers feel that their patients are actively involved in their own care; and,
• You see a significant improvement in patient health status, adherence, engagement, level of utilization and patient/provider experience.
-- Steve WilkinsMind the Gap

What is Patient-Centred Care?

Patient-centered care means involving patients in the planning, delivery and evaluation of health care where it really counts in terms of outcomes, patient adherence, cost reduction and fewer re-hospitalizations.
Being patient-centered is like doing a market research study and then implementing the findings. Patient-centered care does not give absolute control to patients, it simply invites them into the party and gives them a place at the table. As providers, we don’t do a good job of listening to patients. We do an even worse job when it comes to acting on what patients tell us they want.
-- Steve WilkinsMind the Gap

Guiding Principles For Patient-Centred Care

1. Care is based on continuous healing relationships.
2. Care is customized and reflects patient needs, values and choices.
3. Families and friends of the patient are considered an essential part of the care team.
4. Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers.
5. Patient safety is a visible priority.
6. The patient is the source of control for his or her care.
7. All team members are considered caregivers.
8. Care is provided in a healing environment of comfort, peace and support.
9. Transparency is the rule in the care of the patient.
10. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient. (Borrowed from Margaret Gerteis et al.(Through the Patient’s Eyes)

Canada on Top:

Canada was in the top spot for the number of accidental punctures or lacerations during surgery out of the 17 countries surveyed by the Organization for Economic Co-operation & Development (OECD).

At 525 per 100,000 hospitalizations, its rate was more than three times as high as Britain (174) and the U.S. (166).

Patient Engagement:

“Almost half of Canadians with a regular doctor feel engaged in their healthcare. By engaged, we mean that patients always have enough time during visits, can always ask questions about recommended treatment, and are as involved as they want to be in decisions about their care.”

– Health Council of Canada Bulletin 5
September, 2011

Learning Organization

According to David Carnevale, author of Trustworthy Government, one of the key differences between learning organizations and traditional controlling organizations “is that deeply ingrained defensiveness so characteristic of low-trust, traditional bureaucratic organizations undermines necessary learning. Trust expedites learning.”
Carnevale says that “Healthy learning organizations are managed with the objective of liberating and using employee know-how to improve work processes. The emancipation of employee know-how is enabled through a different philosophy of organization and job design, communication patterns, labor-management relations, participatory methods, and other processes that reduce the climate of fear and allow staff the necessary psychological peace of mind to fully engage their work”.

Assumption of Competence

Traditional bureaucratic organizations are dominated by the need for control and conformity -- assuming that workers are incompetent, and therefore must be carefully managed. In turn, this creates high degrees of mistrust, defensiveness and fear -- all of which undermine learning.

In learning organizations, the assumption of competence is supported through the encouragement of curiosity, creativity and innovation. The people who deliver the organization’s services directly to its customers are encouraged to use their know-how to improve work processes. While successes are a cause for celebration, learning organizations must also accept and forgive mistakes as part of the learning process. They must be open to learning from their “best mistakes”.

Leadership/Adaptive

Adaptive leadership means raising tough questions rather than providing answers; it means framing the issues in a way that encourages people to think differently, rather than laying out a map of the future; it means co-creating with people their new roles, power relationships, and behaviors, rather than orienting them in a new direction and giving them a big push.

Shared Vision

At its simplest level, a shared vision is the answer to the question: “What do we want to create. A shared vision is the vision that people throughout an organization or a community of organizations carry about what we want to be in the future.
Peter Senge describes the concept of a Shared Vision in his book The Fifth Discipline. He writes, “a shared vision is not an idea. It is, rather, a force in people’s hearts, a force of impressive power. It may be inspired by an idea but once it goes further - if it is compelling enough to acquire the support of more than one person - then it is no longer an abstraction. It is palpable. People begin to see it as if it exists. Few, if any, forces in human affairs are as powerful as a shared vision.”

Shifting Gears Report:

“Devolve decision-making selectively and where appropriate. Policy makers should consider expanding the accountability functions of regional bodies, strengthening specialty care networks, and supporting organic mergers and acquisitions within the system. Any system transformation primarily focused on significant governance reforms—for example by reinventing regional bodies from scratch—could actually distract attention from the more organic reforms needed that will have a positive impact on fiscal sustainability and produce unnecessary delay in implementing transformative change.”
– University of Toronto

Health Care & Physicians Costs

“A healthy economy and shrinking government debt over the past decade seem to have been the main drivers for soaring health-care spending, while the much-feared aging of the population is having relatively little impact on medicare's bottom line, a new federal-provincial report concludes.
CIHI said that total health spending - by governments as well as private individuals and health plans - is set to reach $200-billion this year, about $5,800 per person. That is an increase of 4%, the smallest one in 15 years.
A separate report looked at the drivers of health spending between 1998 and 2008, when the figure rose by an average of 7.4% per year.
Spending on physicians is the fastest-growing chunk of the budget now, with the increase for 2011 projected to slow slightly to 5.6%. More doctors are being added to the system - 6,500 between 2005 and 2009 - while their income rose by an average of 3.6% per year. That followed a period from 1975 to 1998, however, when MD compensation rose more slowly than other public goods and services.”